Mental Health Concerns in Native Americans

Introduction

            There are more than six million indigenous peoples in the United States that belong to over five hundred recognized tribes (Roessel, 2020) that speak over two hundred languages (American Psychiatric Association, 2017). Indigenous people in the United States may refer to themselves as indigenous or as Native American or American Indian, but all are descendants of the people who populated North America before the arrival of Western European explorers (Department of Health and Human Services, 2001). As members of sovereign nations within a nation, Native Americans are unique among minority cultures in the United States and have a long, traumatic history with European colonizers which may contribute to the disproportionately high rate of mental health disorders (Department of Health and Human Services, 2001; American Psychiatric Association, 2017).   

Contextual Influence in the United States

Though they are unique in the United States due to federal recognition of multiple sovereign nations, Native Americans have been killed, subjugated, and oppressed for hundreds of years. Native American populations have had their land forcibly taken, have been forced into boarding schools and reservations, and have faced extreme discrimination since the arrival of the first Western Europeans to North America (Department of Health and Human Services, 2001; Evans-Campbell et al., 2012). This has created generational trauma in the Native American population that creates a higher prevalence of mental illness than the general population of the United States (Kirmayer et al., 2014; Department of Health and Human Services, 2001).

Currently, only about one third of all Native Americans live on reservations and many live in urban centers around the United States (American Psychiatric Association, 2017). Today, many Native Americans practice Christianity with some incorporating native beliefs and practices (The Substance Abuse and Mental Health Services Administration, 2018). In 2014, 79.2 percent of Native Americans ages 12 to 17 reported that religious beliefs are important to them and 72.3 percent believed that religious beliefs influence their decisions (Center for Behavioral Health Statistics and Quality, 2015). Native Americans today are more likely to face poverty, unemployment, trauma, criminal victimization, physical health problems and dis­parities, and mental and substance use disorders (The Substance Abuse and Mental Health Services Administration, 2018) all of which contribute to a lifespan that is 4.4 years shorter than the rest of the United States (American Psychiatric Association, 2017). However, they draw on their cultures, communi­ties, and families to be resilient in the face of these issues.

When discussing the mental health of Native Americans, it is vital to understand the historical oppression and genocide of indigenous peoples in the Americas. In fact, some researchers have called the initial contact between Native Americans and Europeans the American Indian Holocaust (Kirmayer et al., 2014). The extreme loss of life and forced assimilation of Native American peoples has created intergenerational trauma that must be addressed in any therapeutic contact as research has shown that the transgenerational impacts of violence and forced assimilation are increased risk of Post-Traumatic Stress Disorder, depression, and anxiety (Roessel, 2020; Kirmayer et al., 2014).

Historical Context

          Native Americans, from the first contact of Europeans in the early 17th century to present day reservations, have experienced oppression, prejudice, and violence (Roessel, 2020). There is evidence that Native Americans have inhabited what is now the United States for over seventy-five thousand years and, prior to Columbus’ landing in 1492, their population was up to twelve million. By the year 1900, less than two hundred and fifty thousand Native Americans remained (Grandbois, 2005). To understand this near extinction of a whole people a timeline of events is required.

          After Columbus’ arrival in the Caribbean in 1492, contact with Europeans became more and more common. With each contact more disease was spread among the indigenous population for which they had no immunity. It is estimated that up to ninety percent of the Native American population was killed by communicable diseases brought by European colonizers (Grandbois, 2005).

          Wars for land quickly broke out between the colonialists and Native Americans. Between the 16th century and 1923 there were ninety-five recognized wars between European colonies and Native Americans, the majority of which were fought in the 19th century (Indian Land Tenure Foundation, 2018). The Indian Removal Act of 1820 forced thousands of Native Americans from their ancestral lands to western territories not inhabited by Europeans and precipitated many of these wars (Department of Health and Human Services, 2001). Massacres, treaties, and breaking treaties were common during this period. After the forced marches, often in the dead of winter, and the wholesale slaughter of Native American men, women, and children in the various wars of the 19th century, Native Americans were eventually settled onto reservations (The Substance Abuse and Mental Health Services Administration, 2018; Grandbois, 2005). The most famous of the forced marches to clear Native Americans from ancestral land is the Trail of Tears, perpetrated in 1838, which forced the Cherokee tribe to march from North Carolina to Oklahoma (Indian Land Tenure Foundation, 2018).

          In the later part of the 19th century, after the majority of Native Americans had been moved to reservations, the United States government began systematic forced assimilation through the boarding school system (Evans-Campbell et al., 2012). This was, in practice, a second forced migration as nearly half of all Native American children were forced from the reservations to attend one of the twenty-six off reservation schools (Department of Health and Human Services, 2001; Evans-Campbell et al., 2012). Native American children in these schools were not allowed to speak their language, practice their religious rites, or engage in any cultural practices in hopes of assimilating Native Americans out of existence. Children were also neglected and sexually abused, adding to the already immense trauma faced by their people (Department of Health and Human Services, 2001).  

This legacy of violence, forced migration, forced assimilation, and marginalization has created one of the largest losses of cultural identity in recorded history. Many tribes present in the United States before colonization were terminated and many more tribal cultures were forcibly beaten out of Native American children (Evans-Campbell et al., 2012). Native Americans have had to reconstruct and restore much of their cultural heritage that was lost due to hundreds of years of systematic acts of aggression, forced relocation, and cultural suppression (Kirmayer et al., 2014).

          It was not until the late 1960’s through to the 1980’s that Native Americans were granted rights and freedoms similar to those of citizens of European descent (Indian Land Tenure Foundation, 2018). However, broken treaties, tribal sovereignty, and reparations are still issues that Native Americans are fighting for. Protections for cultural sites such as burial grounds were not established until 1990 and reservation land disputes are still common (The Substance Abuse and Mental Health Services Administration, 2018).           
Family Structure and Family Dynamics in Treatment Options

          Hundreds of years of forced migration and forced assimilation completely shattered Native American families. Children being forcibly removed from their families to attend boarding schools designed to beat out their culture created broken families. The fact that many of these schools were not closed until the 1970’s gives an idea of how recent this violent disruption in family dynamics is (Evans-Campbell et al., 2012). The effects of these boarding schools can be seen in the parenting practices of some Native Americans to this day (Roessel, 2020).

Family is, unsurprisingly, extremely important to Native Americans. Many Native American families are headed by a single female and are slightly larger than the size of all United States families. Native American families also have more dependents as a household can include extended family and even non-blood related members (The Substance Abuse and Mental Health Services Administration, 2018).  Many Native American families are also matrilineal, meaning that “families may trace their ancestral lineages through the maternal side, pass property through female heirs, grant women key decision-making roles in governance, and readily assign custody to mothers or grandmothers” (The Substance Abuse and Mental Health Services Administration, 2018 p. 32). While this may be more related to culture than assimilation, it is important to note that these matrilineal practices were forbidden under the termination of Native American culture.

These family dynamics and structures are important to keep in mind for treatment options. Due to the central nature of family in Native American culture, it is important to expect families to be more involved in treatment than the families of other ethnicities (The Substance Abuse and Mental Health Services Administration, 2018 p. 32). While some of the current family structures are reconstructions of a cultural heritage that was forcibly removed from Native Americans, some of them are also due to the historical and intergenerational trauma Native Americans have experienced (Kirmayer et al., 2014). Increased family involvement in treatment, therefore, can be seen as both a cultural value and a response to the traumatic legacy of boarding schools. 

Implications of Cultural Dynamics

          For therapists working with Native American populations, it is important to keep in mind that there are over five hundred recognized tribes in the United State today, each with its own culture, values, and dynamics. It is necessary for cultural competence to learn about the specific culture or mix of cultures of a client (The Substance Abuse and Mental Health Services Administration, 2018). Even so, there are common values that many Native American people share that are critical for therapists to know.

Cooperation, collectivism, and harmony are high importance values in Native American culture. As many Native Americans historically relied on cooperation and sharing to survive, it is easy to see how this value would survive into the present day. An emphasis on harmony with nature and others necessitates a consensus strategy for making decisions rather than a majority rule(The Substance Abuse and Mental Health Services Administration, 2018). This focus on harmony and cooperation are important to take into account when challenging or disagreeing with Native American clients. It may also make the therapeutic alliance stronger and easier to maintain.

Growing out of the culture of cooperation and harmony, modesty and humility are also core Native American values. This means that self-aggrandizement, even if it may be in the best interest of the individual, is considered inappropriate for the collective. Words may be used sparingly as they have great power and extended eye contact may be considered a challenge (The Substance Abuse and Mental Health Services Administration, 2018). Rather than disengagement or low self-worth, these are hallmarks of respect and humility that are valued in Native American culture.

Respect is another very important value in Native American culture. Respect for personal freedom and individual autonomy as well as respect for tradition and elders are paramount. While these may seem a bit contradictory, it makes sense within the wider cultural zeitgeist. For cooperation to be successful, each individual within the group must be competent to work for the good of the community. Personal advice runs contrary to this value as it may suggest that the person is not competent to deal with the concern themselves (The Substance Abuse and Mental Health Services Administration, 2018). Respect for elders and tradition is extremely important to Native Americans who have been forcibly cut off from their traditions. Elders are usually the keepers of these traditions and are therefore to be respected.

In keeping with the values of cooperation and harmony, work is seen as a way to meet needs rather than to accumulate wealth. Traditionally Native Americans did not stockpile resources and instead held resources to be communally owned. In many native languages there is not even a word for ownership (The Substance Abuse and Mental Health Services Administration, 2018). Giving is considered something that raises your status within the group, rather than accumulation of possessions, which runs contrary to the United States’ capitalistic culture where success is measured in personal wealth. It is important to understand that personal wealth may not be a priority for Native American clients.

Along the same lines, Native American culture puts more emphasis on the present than the future. This makes sense in the context of another value, respecting nature. In Native American culture, all of nature is sacred and worthy of respect. Traditionally, Native Americans received all material resources from nature and keeping a balance helped those resources flourish. In this way, staying in the present makes much more sense ownership (The Substance Abuse and Mental Health Services Administration, 2018). Living day to day and paying attention to the natural world around helps to keep that balance with nature and insure the survival of the tribe. This must be kept in mind when discussing future goals with clients with Native American ancestry. 

This also links with the idea that the spiritual and material are not separate. For Native Americans, the spiritual pervades daily life and the natural world itself can be perceived as spiritual or mystical (Gone, 2004). It is important that clinicians keep in mind this pervasive spirituality when assessing for psychosis as well as in discussing ideas about material wealth and indicators of success. Native American clients may also find spiritual lessons in nature and this may be helpful for the clinician to build upon.

Suggestions for Practice

          As a therapist working with a Native American client, I would consider two issues to be paramount above and beyond the cultural implications discussed above. The first is that complementary treatment with traditional healers can be extremely beneficial. The second is that inpatient treatment, especially for children or adolescents, must be used only as a last resort.

          Research shows that the use of traditional medicine and healers in conjunction with contemporary mental health care is beneficial to Native American populations (Department of Health and Human Services, 2001). Mental illness can be conceptualized by Native Americans as an imbalance with nature, a spiritual gift, a possession, as a medical disorder, or as a combination of any or all of these (Grandbois, 2005). Due to the multiple cultural conceptualizations and the history of marginalization and forced assimilation, utilizing traditional medicine and working with tribal elders and healers can be very beneficial (Gone, 2004). Mind-body and eco interventions can also be helpful if used in a culturally competent way (Grandbois, 2005). Utilizing psychotherapy with mind-body and eco interventions together with traditional medicines and healers is also a collaborative treatment plan that works in harmony with the client’s community. 

          The traumatic history of boarding schools where Native American children were forced from their families in order to be assimilated into the dominant culture still holds wounds. Many Native Americans are suspicious of “White man’s medicine” and what it may mean to their family and culture (Grandbois, 2005). Those who are put in residential treatment facilities may face stigma from their family or community for acting too “White” when they return home, regardless of individual feelings of progress. Utilizing residential treatment may trigger intergenerational trauma and will separate the client from their family and community, which is a culturally significant source of support. For these reasons, it is suggested that inpatient or residential treatment be considered only as a last resort.

Conclusion

Native Americans are a diverse and unique cultural minority in the United States. Their unique status as members of sovereign nations within a nation, as well as being indigenous to North America before European colonization creates a confluence of historical trauma and forced assimilation that has lead to higher rates of mental health concerns (Department of Health and Human Services, 2001). Treatment of Native Americans must take into consideration the unique family dynamics, such as matrilineal descent, as well as cultural values that were once forcibly stripped from them, creating intergenerational trauma. Understanding Native American history and culture and how it intersects with the dominant culture of the United States is paramount in effectively and competently working with this population.

References

American Psychiatric Association. (2017). American Indians and Alaska Natives. In psychiatry.org.

Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. NSDUH Series H-50, HHS Publication No. (SMA) 15-4927. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Evans-Campbell, T., Walters, K. L., Pearson, C. R., & Campbell, C. D. (2012). Indian Boarding School Experience, Substance Use, and Mental Health among Urban Two-Spirit American Indian/Alaska Natives. The American Journal of Drug and Alcohol Abuse, 38(5), 421–427. https://doi.org/10.3109/00952990.2012.701358

Gone, J. P. (2004). Mental Health Services for Native Americans in the 21st Century United States. Professional Psychology: Research and Practice, 35(1), 10–18. https://doi.org/10.1037/0735-7028.35.1.10

Grandbois, D. (2005). STIGMA OF MENTAL ILLNESS AMONG AMERICAN INDIAN AND ALASKA NATIVE NATIONS: HISTORICAL AND CONTEMPORARY PERSPECTIVES. Issues in Mental Health Nursing, 26(10), 1001–1024. https://doi.org/10.1080/01612840500280661

Indian Land Tenure Foundation. (2018). American Indian History Timeline. Indian Land Tenure Foundation.

Kirmayer, L. J., Gone, J. P., & Moses, J. (2014). Rethinking Historical Trauma. Transcultural Psychiatry, 51(3), 299–319. https://doi.org/10.1177/1363461514536358

Roessel, M. H. (2020). Best Practice Highlights. In psychiatry.org. American Psychiatric Association. https://www.psychiatry.org/psychiatrists/cultural-competency/education/best-practice-highlights/working-with-native-american-patients

The Substance Abuse and Mental Health Services Administration. (2018). Behavioral Health Services for American Indians and Alaska Natives. Treatment Improvement Protocol (TIP) Series 61. HHS Publication No.(SMA) 18- 5070EXSUMM. Substance Abuse and Mental Health Services Administration.

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